Voids in regulatory guidance for development of theragnostic radiopharmaceuticals in oncology.

e23044 Background: A new generation of targeted anticancer radiopharmaceuticals is experiencing rapid advancement and increased clinical evaluation. However, the regulatory framework has not kept pace with scientific progress. This presentation identifies and analyzes regulatory guidance gaps for diagnostic and therapeutic (theragnostic) anticancer radiopharmaceuticals and recommends strategies to overcome these challenges. Methods: A systematic review of regulatory guidelines from FDA, NRC, and EMA was conducted, focusing on clinical development of anticancer radiopharmaceuticals. Recent FDA and EMA approvals were analyzed, and a gap analysis was performed to identify areas with insufficient or absent regulatory guidance. Requirements for non-clinical studies or manufacturing processes are beyond the scope of this review. Results: Key voids in regulatory guidance include: Lack of comprehensive guidelines for in vivo companion diagnostics, such as targeted diagnostic radiopharmaceuticals Absence of formal written guidelines for clinical development of therapeutic radiopharmaceuticals Limited guidance on optimal design of clinical trials for theragnostic combinations Lack of formal recommendations for dosage optimization Insufficient guidance for development and use of radiopharmaceuticals in Pediatric Oncology. Future Directions: Proactive engagement between radiopharmaceutical developers and regulatory authorities Collaboration between sponsors and regulatory agencies to explore innovative clinical trial designs, such as adaptive trials, including validation of novel endpoints specific to these agents Patient organization advocacy for international harmonization of guidelines FDA and EMA consideration of radiopharmaceutical-specific guidance on dose optimization Prioritization of pediatric development strategies on behalf of agencies and pharmaceutical companies. Conclusions: The regulatory landscape for anticancer radiopharmaceuticals shows significant shortcomings in formal written guidance on recommendations for clinical development. These gaps include inadequate guidance for in vivo companion diagnostics, limited support for theragnostic development, and a lack of specific guidance for dose optimization and pediatric populations. Addressing these regulatory voids is important, necessitating a collaborative strategy involving regulatory bodies, industry, and patient organizations. Developing comprehensive, up-to-date guidelines that account for the distinct nature of these medicinal products is crucial to facilitate the development and approval of safe, effective theragnostic radiopharmaceuticals and improve patient outcomes. Keywords: Radiopharmaceuticals, Theragnostic, Anticancer, Regulation, Guidelines.